Listening to women's voices: the experience of giving birth with paramedic care in Queensland, Australia

Background

Unplanned out-of-hospital birth is generally assumed to occur for women who are multiparous, have a history of a short pushing phase of labour or are experiencing a precipitate birth. However, there is little research that examines the woman’s perspective regarding factors that influenced their decision on when to access care. This research aimed to explore women’s experience of unplanned out-of-hospital birth in paramedic care. Due to the size of the data in the larger study of ‘Women’s experience of unplanned out-of-hospital birth in paramedic care’ [1], this paper will deal directly with the women’s narrative concerning her decision to access care and how previous birth experience and interactions with other healthcare professionals influenced her experience.

Method

Narrative inquiry, underpinned from a feminist perspective, was used to guide the research. Twenty-two women who had experienced an unplanned out-of-hospital birth within the last 5 years in Queensland, Australia engaged in this research.

Results

The decision of a woman in labour to attend hospital to birth her baby is influenced by information received from healthcare providers, fear of unnecessary medical intervention in birth, and previous birth experience. All themes and subthemes that emerged in the women’s narratives relate to the notion of birth knowledge. These specifically include perceptions of what constitutes authoritative knowledge, who possesses the authoritative knowledge on which actions are based, and when and how women use their own embodied knowledge to assess the validity of healthcare workers’ advice and the necessity for clinical intervention.

Conclusions

The women interviewed communicated a tension between women’s knowledge, beliefs and experience of the birth process, and the professional models of care traditionally associated with the hospital environment. It is essential that information provided to women antenatally is comprehensive and comprehensible. The decisions women make concerning their birth plan represent the women’s expectations for their birth and this should be used as a means to openly communicate issues that may impact the birth experience.

Women's experience of unplanned out-of-hospital birth in paramedic care

BACKGROUND

Healthcare literature describes predisposing factors, clinical risk, maternal and neonatal clinical outcomes of unplanned out-of-hospital birth; however, there is little quality research available that explores the experiences of mothers who birth prior to arrival at hospital.

METHODS

This study utilised a narrative inquiry methodology to explore the experiences of women who birth in paramedic care.

RESULTS

The inquiry was underscored by 22 narrative interviews of women who birthed in paramedic care in Queensland, Australia between 2011 and 2016. This data identified factors that contributed to the planned hospital birth occurring in the out-of-hospital setting. Women in this study began their story by discussing previous birth experience and their knowledge, expectations and personal beliefs concerning the birth process. Specific to the actual birth event, women reported feeling empowered, confident and exhilarated. However, some participants also identified concerns with paramedic practice; lack of privacy, poor interpersonal skills, and a lack of consent for certain procedures.

CONCLUSIONS

This study identified several factors and a subset of factors that contributed to their experiences of the planned hospital birth occurring in the out-of-hospital setting. Women described opportunities for improvement in the care provided by paramedics, specifically some deficiencies in technical and interpersonal skills.

Unplanned out-of-hospital birth and risk factors of adverse perinatal outcome: findings from a prospective cohort

Background

In France, while most babies are delivered at hospital, emergency medical services (EMS) weekly manage calls for unplanned out-of-hospital births. The objective of our study was to describe neonatal morbidity and mortality, defined as death or neonatal intensive care unit hospitalization at Day 7, in a prospective multicentric cohort of unplanned out-of-hospital births.

Methods

We prospectively analyzed out-of-hospital births from 25 prehospital EMS units in France. The primary outcome was neonatal morbidity and mortality, and the secondary outcome was risk factors associated with neonatal morbidity and mortality. A univariate logistic regression was first made, followed by a multivariate logistic regression with backward selection.

Results

From October 2011 to August 2018, a total of 1670 unplanned out-of-hospital births were included. Of these, 1652 (99.2%) were singleton and 1537 (93.5%) had prenatal care. Maternal mean age of the study population was 30 ± 5.5 (range 15 to 48). The majority of women were multiparous, but 13% were nulliparous. Overall, 45.3% of these unplanned out-of-hospital births were medically-driven, either by phone during medical regulation (12.5%) or on scene by the prehospital emergency medical service units (32.9%). The prevalence of neonatal morbidity and mortality was 6.3% (n = 106) after an unplanned out-of-hospital birth (death before Day 7: n = 20; 1.2%). The multivariate logistic regression found that multiparity (adjusted Odds Ratio = 70.7 [4.7–1062]), prematurity (adjusted Odds Ratio = 6.7 [2.1–21.4]), maternal pathology (adjusted Odds Ratio = 2.8 [1.0–7.5]) and hypothermia (adjusted Odds Ratio = 2.8 [1.1–7.6]) were independent predictive factors of neonatal morbidity and mortality.

Conclusions

Our study assessed for the first time risk factors for adverse perinatal outcome in a large and multicenter cohort of unplanned out-of-hospital births. We have to improve temperature management in the out-of-hospital field and future trials are required to investigate strategies to optimize newborns management in the prehospital area.

Electronic supplementary material

The online version of this article (10.1186/s13049-019-0600-z) contains supplementary material, which is available to authorized users.

Specialist ambulance nurses' experiences of births before arrival

BACKGROUND

Working as an ambulance nurse means interacting with and caring for acutely ill and injured patients. It can even involve births before arrival to the hospital (BBA), which are rare but increasing due to the centralization of maternity wards.

AIM

This study describes the experiences of specialist ambulance nurses with BBA.

METHOD

A qualitative study was conducted, and nine specialist ambulance nurses who had assisted with one or more prehospital births were interviewed. Data were analysed with thematic content analysis.

FINDINGS

The analysis revealed three categories that were compiled into a theme of feeling fright and exhilaration. The findings showed that BBA causes feelings of anxiety and stress. The experience is also associated with joy and relief when the baby is born. Childbirth is a situation for which specialist ambulance nurses feel less prepared, lack of knowledge, and wish for more education.

CONCLUSION

Specialist ambulance nurses face challenges in the pre-hospital care environment during BBA, with long distances, a lack of equipment aboard the ambulance, and no assistance from midwives. To feel secure in the complex role that is required when assisting with a BBA, specialist ambulance nurses should be given the opportunity to receive scenario training.

Epidemiology of unplanned out-of-hospital births attended by paramedics

BACKGROUND

Over the previous two decades the incidence and number of unplanned out of hospital births Victoria has increased. As the only out of hospital emergency care providers in Victoria, paramedics would provide care for women having birth emergencies in the community. However, there is a lack of research about the involvement of paramedics provide for these women and their newborns. This research reports the clinical profile of a 1-year sample caseload of births attended by a state-wide ambulance service in Australia.

METHODS

Retrospective data previously collected via Victorian Ambulance Clinical Information System (VACIS ®) an in-field electronic patient care record was provided by Ambulance Victoria. Cases were identified via a comprehensive filter, and analysed using SPSS version 19.

RESULTS

Over a 12-month period paramedics attended 324 out-of-hospital births including 190 before paramedics' arrival. Most (88.3%) were uncomplicated precipitous term births. However, paramedics documented various obstetric complications including postpartum haemorrhage, breech, cord prolapse, prematurity and neonatal death. Furthermore, nearly one fifth (16.7%) of the women had medical histories that had potential to complicate their clinical management, including taking illicit or prescription drugs. Mothers were more likely to be multiparas. Births were more likely to occur between 2200 and 0600 h. Paramedics performed a range of interventions for both mothers and babies.

CONCLUSIONS

Paramedics provided emergency care for prehospital out-of-hospital births. Although most were precipitous uneventful births at term, paramedics used complex obstetric assessment and clinical skills. These findings have implications for paramedic clinical practice and education around management of unplanned out of hospital births.

Maternal characteristics and birth outcomes resulting from births before arrival at health facilities in Nkangala District, South Africa: a case control study

BACKGROUND

Risks of severe, avoidable maternal and neonatal complications at birth are increased if the birth occurs before arrival at the health facility and in the absence of skilled birth attendants. Birth Before Arrival (BBA) is a preventable phenomenon still common in modern-day practice despite extensive improvements made in obstetric care and in accessibility to healthcare in South Africa. This study aimed to determine the risk factors and outcomes in mothers and babies associated with being born before arrival at hospitals.

METHODS

A prospective case control study design was conducted. All BBAs presenting to the hospitals in Nkangala District between November 2015 and February 2016 were included and compared to a consecutive hospital delivery occurring immediately after the arrival of each BBA. T-tests and chi square tests were used to analyse the differences between the groups and a binary logistic regression analysis used to determine predictors of BBAs. All statistical analysis were done using STATA version 14 using a 5% decision level and a 95% confidence interval.

RESULTS

During the study period, 4397 in-facility births and 201 BBAs were recorded, 78 BBAs and 75 controls were investigated in this study. The district BBA prevalence was 4.6%. Risk factors identified in mothers of BBAs were: single mothers (83.3% vs 69.3%; p = 0.04); residing in an informal settlement (23.1% vs 5.3%; p = 0.002); and higher gravidity with plurigravida significantly more (60.3% vs 32.5%; p < 0.0001). A prevalent maternal complication in cases was haemorrhage due to retained placenta. Most neonates were born alive with a higher proportion of cases experiencing perinatal complications such as respiratory distress, hypothermia and asphyxia. No significant differences in maternal age, employment status and immediate birth outcomes were found. Residing in informal settlements, higher gravidity, unplanned pregnancy, low birth weight and unbooked were found to predict the occurrence of BBAs.

CONCLUSION

Although no significant numbers of mortalities were recorded in this study, service delivery interventions targeting the reduction of BBAs are needed so as to minimise the morbidity experienced by the group.

Poverty, partner discord, and divergent accounts; a mixed methods account of births before arrival to health facilities in Morogoro Region, Tanzania

Background

Births before arrival (BBA) to health care facilities are associated with higher rates of perinatal morbidity and mortality compared to facility deliveries or planned home births. Research on such births has been conducted in several high-income countries, but there are almost no studies from low-income settings where a majority of maternal and newborn deaths occur.

Methods

Drawing on a household survey of women and in-depth interviews with women and their partners, we examined the experience of BBA in rural districts of Morogoro Region, Tanzania.

Results

Among survey respondents, 59 births (4 %) were classified as BBAs. Most of these births occurred in the presence of a family member (47 %) or traditional birth attendant (24 %). Low socioeconomic status was the strongest predictor of BBA. After controlling for wealth via matching, high parity and a low number of antenatal care (ANC) visits retained statistical significance. While these variables are useful indicators of which women are at greater risk of BBA, their predictive power is limited in a context where many women are poor, multiparous, and make multiple ANC visits. In qualitative interviews, stories of BBAs included themes of partner disagreement regarding when to depart for facilities and financial or logistical constraints that underpinned departure delays. Women described wanting to depart earlier to facilities than partners.

Conclusion

As efforts continue to promote facility birth, we highlight the financial demands associated with facility delivery and the potential for these demands to place women at a heightened risk for BBAs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1058-x) contains supplementary material, which is available to authorized users.

Urgent EMS managed out-of-hospital delivery dispatches in Helsinki

BACKGROUND

The aim of this study was to examine Helsinki Emergency Medical Services (EMS) and hospital records to determine the incidence and possible complications of out-of-hospital deliveries managed by EMS in Helsinki.

METHODS

We retrospectively analysed all urgent ambulance dispatches relating to childbirth in Helsinki from January 1, 2010 to December 31, 2014 with further analysis of hospital records for the out-of-hospital deliveries. Patients were divided in to two groups: those who delivered before reaching hospital and those who did not deliver before reaching hospital and differences between groups were analysed. Deliveries with gestational age of at least 22 + 0 weeks were considered as births in statistical analysis as this is the current national practice.

RESULTS

There were 799 urgent dispatches during the study period. In 102 (12.8 %) of these delivery took place before reaching the hospital. The incidence of EMS managed out-of-hospital delivery was found to be 3.0/1000 births. The annual number of out-of-hospital deliveries attended by EMS increased from 15 in 2010 to 28 in 2014. No stillbirths were reported. Neither maternal or perinatal deaths nor major maternal complications were noted in the study population.

DISCUSSION

Out-of-hospital deliveries represent a small minority of EMS calls and remain a challenge to maintaining professional capabilities. Small sample size might have limited the ability of the study to pick up rare complications.

CONCLUSIONS

The amount of out-of-hospital deliveries in Helsinki increased during the five-year study period. There were no maternal or perinatal mortality or major complications resulting in long-term sequelae associated with the EMS-managed out-of-hospital births.